OESOPHAGO-GASTRIC TRANSIT FOLLOWING SLEEVE GASTRECTOMY: MECHANISM OF RAPID GASTRIC EMPTYING
Yazmin Johari*1,2, Anagi Wickremasinghe1, Gilian Lim1, Helen Yue2, Geraldine Ooi1,2, Cheryl Laurie1, Geoffrey Hebbard3, Paul Beech2, Paul Burton1,2, Wendy Brown1,2
1Monash University, Melbourne, Victoria, Australia; 2Alfred Health, Melbourne, Victoria, Australia; 3Royal Melbourne Hospital, Melbourne, Victoria, Australia
INTRODUCTION Patients who undergo sleeve gastrectomy have substantially altered anatomy and demonstrate rapid gastric emptying. The physiological mechanics after sleeve gastrectomy, particularly oesophago-gastric transit, are incompletely elucidated and would be of significant value.
AIM: To determine the mechanisms of oesophago-gastric transit following sleeve gastrectomy.
METHODS: There were 26 participants post-surgery demonstrating optimal progress (by structured clinical interview) and 21 obese controls. Nuclear scintigraphy using high definition (XelerisTM 4 DR) imaging, semi-solid dynamic contrast swallows, high-resolution stationery manometry and concurrent fluoroscopy were performed.
RESULTS: Demographic data was similar: Sleeve gastrectomy age 47.3±11.8 vs 40.7±13.0years (p=0.140), 19 vs 10females (p=0.391), pre-operative BMI 47.5±6.6 vs 45.8±6.6(p=0.479). Excess weight loss was 62.2±28.1% and duration from surgery 15±23months. Post-surgery; mild to moderate delay in oesophageal transit during swallows (liquid; n=15, semi-solid; n=14). Gastric emptying half time was 25.4±12.5 minutes (gastric sleeve) compared to 70.7±44.7 minutes (controls) (p<0.0001). Post gastric sleeve, 35±17% of meal transited into the small bowel in the first two minutes of acquisition, compared to 19±13% (p<0.004). Post-operatively, prolonged oesophageal substrate retention with graduated co-dependence clearance was observed. Stress barium illustrated a pattern of continuous (69%) or cyclical (31%) emptying, with a consistent 5 stage cyclical pattern involving likely repeat oesophageal peristalsis, incisural opening and subsequent transpyloric flow in concert with pan-compartmental pressurisation of the vertical compartment.
CONCLUSIONS Following sleeve gastrectomy; delayed oesophageal transit, rapid gastric emptying and hyper-accelerated transit of meal into the small bowel are observed. An ordered oscillatory pattern of compartmental filling and subsequent transpyloric flow, leads to bolus transit rather than regulated emptying. The mechanism of rapid gastric emptying is via transmitted oesophageal pressurisation of the vertical compartment generating reflex antral contractions and subsequent trans-pyloric flow.
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